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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800912
Report Date: 08/28/2024
Date Signed: 08/28/2024 12:23:11 PM

Document Has Been Signed on 08/28/2024 12:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BEACONLIGHT CARE HOMEFACILITY NUMBER:
216800912
ADMINISTRATOR/
DIRECTOR:
HYPPOLITE, WALLYFACILITY TYPE:
735
ADDRESS:1468 SOUTH NOVATO BLVDTELEPHONE:
(415) 756-5525
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 6CENSUS: 6DATE:
08/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Director- Wally HyppoliteTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
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08/28/2024, Licensing Program Analyst (LPAs) Loera and Felias conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently six(6) clients in care. Upon arrival three(3) out of six(6) clients were at day program. Facility approved/cleared for two non-ambulatory.

At approximately 9:30am, LPAs and Director toured the building and grounds. The facility was found to be at a comfortable temperature with all exits free of obstruction. LPAs observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated.

All rooms were equipped with lighting, night stand, and drawers. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care were measured 112.1 within the range of 105 to 120 degrees F. Fire extinguishers were last inspected May, 2024. Smoke/Carbon Monoxide detectors are hard wired and located throughout the facility were tested and operational. Toxins, sharps and other items that could pose threat if available to clients were located in a locked cabinet in the kitchen and found to be secured.

LPAs conducted spot medication check and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. P&I monies were documented, secure and not commingled.

At approximately 10:30 am, LPAs conducted a review of six client records. All records had the required documentation.

At approximately 11:00 am, LPA conducted review of four(4) staff records/training. Upon a review of staff records, LPAs found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.

Continued on LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BEACONLIGHT CARE HOME
FACILITY NUMBER: 216800912
VISIT DATE: 08/28/2024
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Liability Insurance
Emergency Disaster Plan (LIC 610D)
Active and Current Administrator Certificate

No Deficiencies Cited during visit.

Exit interview conducted with Administrator and a copy of this report was provided.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC809 (FAS) - (06/04)
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